2016 GEHA. dental. FEDVIP Plans. let life happen. gehadental.com

Transcription

1 2016 GEHA dental FEDVIP Plans let life happen gehadental.com

2 Smile, you re covered, with great benefits and a large national network. High maximum benefits $25,000 for High Option Growing network of dentists More than 300,000 in-network provider locations nationwide Orthodontia for children and adults Paid at 70% Free preventive care, in-network Exams, X-rays and two cleanings per year Comprehensive coverage Fillings, root canals and other services No deductible No waiting period for most procedures See any dentist Get more details at gehadental.com, or call (877) 590-GEHA.

3 Figure your costs here. 1 In chart one, find your state or ZIP code to determine your rate code. 2 In chart two, match your premium rate code to your plan option (High Option or Standard Option) and enrollment options (Self Only, Self Plus One, or Self and Family). Premium Rate Codes by State / ZIP Code AK All 5 AL All 1 AR All 1 AZ All 2 CA , , CA Rest of the state 4 CO All 4 CT CT Rest of the state 4 DC All 4 DE All 3 FL FL Rest of the state 2 GA , 305, 311, GA Rest of the state 2 HI All 3 IA All 1 IN 463, IN Rest of the state 1 KS All 2 KY 410, 452, KY Rest of the state 1 LA All 2 MA All 4 MD , 214, MD MD Rest of the state 2 ME ME Rest of the state 3 MI MI Rest of the state 2 MN , MN Rest of the state 2 MO All 2 NE All 1 NH All 4 NJ NJ Rest of the state 5 NM All 3 NV All 3 NY 005, , NY NY Rest of the state 2 OH , , OH Rest of the state 1 OK All 2 OR All 3 PA PA PA PA Rest of the state 1 TN Rest of the state 2 TX All 2 UT All 1 VA 201, 205, VA Rest of the state 2 VT All 2 WA WA WA Rest of the state 4 WI WI Rest of the state 2 WV WV Rest of the state 2 WY WY Rest of the state 1 PR All 1 GU All 1 VI All 1 ID All 2 IL MS All 1 MT All 2 RI All 4 SC All 2 FO International + all other areas not listed 1 IL Rest of the state 1 NC All 2 SD All 1 IN , 470, ND All 1 TN Dental Premium Biweekly cost for ACTIVE federal employee Premium Rate High Option Standard Option Schedule * Self Only Self Plus One Self and Family Self Only Self Plus One Self and Family 1 $15.58 $31.17 $46.76 $9.03 $18.07 $ $17.13 $34.27 $51.45 $9.92 $19.85 $ $19.45 $38.92 $58.36 $11.27 $22.53 $ $21.00 $42.00 $63.04 $12.16 $24.32 $ $23.32 $46.67 $70.02 $13.50 $27.01 $40.50 Dental Premium Monthly cost for RETIRED federal employee Premium Rate High Option Standard Option Schedule * Self Only Self Plus One Self and Family Self Only Self Plus One Self and Family 1 $33.76 $67.54 $ $19.57 $39.15 $ $37.12 $74.25 $ $21.49 $43.01 $ $42.14 $84.33 $ $24.42 $48.82 $ $45.50 $91.00 $ $26.35 $52.69 $ $50.53 $ $ $29.25 $58.52 $87.75 *Rates based on member s primary state of residence.

4 Find your benefit summary here. Benefit All classes of service are included in both High Option and Standard Option as part of the plan. This is a brief description of services covered under the GEHA Connection Dental Federal plan. Do NOT rely on this chart alone. All benefits are subject to the definitions, limitations and exclusions set forth in the dental brochure Plan Year Waiting Period Calendar Year Deductible High Option Benefit Plan pays the following percentage of the plan allowance: Standard Option Benefit Plan pays the following percentage of the plan allowance: Calendar year maximum $25,000 / person $2,500 / person In-network Out-of-network* In-network Out-of-network* Basic Class A Exams Cleanings** X-rays None None 100% 100% 100% 100% Intermediate Class B Fillings Extractions Periodontal maintenance None None 80% 80% 55% 55% Major Class C Root canals Crowns Bridges Dentures Periodontal surgery Implants None None 50% 50% 35% 35% Orthodontic Class D Orthodontic services after 12 months None 70% 70% 70% 70% a 12-month waiting period for children and adults * Member pays any difference between the Plan allowance and the billed amount. ** Plans cover two cleanings per calendar year. For High Option, class A, B, and C Covered Services are limited to a combined Calendar Year Maximum Benefit of $25,000. For Standard Option, class A, B, and C Covered Services are limited to a combined Calendar Year Maximum Benefit of $2,500 per covered person. Implants are covered on both the High and Standard Options under the Class C benefit limited to a Calendar Year Maximum Benefit of $2,500 per covered person. Limited to a lifetime maximum of $2,500 under High and Standard Option, per covered person. Pretreatment estimate Before you receive treatment, estimate how much your care will cost. You or your provider can send in an itemized proposed treatment plan and we will send you and your dentist an estimate of how the services will be covered. Choosing a dentist You have the choice of providers. However, for many services, your out-of-pocket costs may be lower when you visit in-network locations. Network providers will not bill you more than the Plan s maximum allowable charge for covered services. Limitations and exclusions This Plan has certain limits on dental coverage in order to keep plan rates affordable for you and your dependents. A complete list of Plan limitations and exclusions may be found in the GEHA Connection Dental Federal Plan Brochure. It's easy to estimate costs. Find pricing information for many common dental procedures at gehadental.com/pricing.

5 Enrollment is easy. Online, go to benefeds.com. Follow the prompts to enroll in GEHA Connection Dental Federal. Or, call toll free (877) TTY: (877)

6 PRESORTED STANDARD U.S. POSTAGE PAID GEHA P.O. Box 2336 Independence, MO gehadental.com (877) 590-GEHA /gehahealth 2015 Government Employees Health Association, Inc. All rights reserved. Please recycle.